- Email: [email protected]
Stigma: The relevance of social contact in mental disorder
+Model
ARTICLE IN PRESS
Enferm Clin. 2017;xxx(xx):xxx---xxx
www.elsevier.es/enfermeriaclinica
ORIGINAL ARTICLE
Stigma: The relevance of social contact in mental disorder夽 Víctor M. Fríasa,b,∗ , Joan R. Fortunya , Sergio Guzmána , Pilar Santamaríaa , Montserrat Martínezc , Víctor Pérezd,e,f a
Institut de Neuropsiquiatria i Addicions, Centre Assitencial Dr. Emili Mira, Parc de Salut Mar, Santa Coloma de Gramenet, Barcelona, Spain b Departament de Psiquiatria, Universitat Autònoma de Barcelona, Barcelona, Spain c Gestió del Coneixement i Avaluació, Hospital Universitari Vall d’Hebron, Barcelona, Spain d Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain e Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain f CIBERSAM, Departament de Psiquiatria, Universitat Autònoma de Barcelona, Barcelona, Spain Received 19 November 2016; accepted 26 May 2017
KEYWORDS Stigma; Social contact; Mental illness; Mental disorder; Schizophrenia; Community programmes
Abstract Introduction: The stigma associated with mental illness is a health problem, discriminating and limiting the opportunities for sufferers. Social contact with people suffering a mental disorder is a strategy used to produce changes in population stereotypes. The aim of the study was to examine differences in the level of stigma in samples with social contact and the general population. Method: The study included two experiments. The first (n = 42) included players in an open football league who played in a team with players with schizophrenia. In the second included, a sample without known contact (n = 62) and a sample with contact (n = 100) were compared. The evaluation tool used was AQ-27, Spanish version (AQ-27-E). The mean difference between the two samples of each of the 9 subscales was analysed. Results: In the first experiment, all the subscales had lower scores in post-contact than in precontact, except for responsibility. The two subscales that showed significant differences were duress (t = 6.057, p = 0.000) and Pity (t = 3.661, p = 0.001). In the second experiment, seven subscales showed a significance level (p < 0.05). Segregation and responsibility and did not.
DOI of original article: http://dx.doi.org/10.1016/j.enfcli.2017.05.007 Please cite this article as: Frías VM, Fortuny JR, Guzmán S, Santamaría P, Martínez M, Pérez V. Estigma: la relevancia del contacto social en el trastorno mental. Enferm Clin. 2017. http://dx.doi.org/10.1016/j.enfcli.2017.05.007 ∗ Corresponding author. E-mail address: [email protected] (V.M. Frías). 夽
2445-1479/© 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.
ENFCLE-688; No. of Pages 7
+Model
ARTICLE IN PRESS
2
V.M. Frías et al. Conclusions: It is observed that the social contact made in daily situations can have a positive impact on the reduction of stigma. This can help to promote equality of opportunity. © 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.
PALABRAS CLAVE Estigma; Contacto social; Enfermedad mental; Trastorno mental; Esquizofrenia; Programas comunitarios
Estigma: la relevancia del contacto social en el trastorno mental Resumen Introducción: El estigma asociado a la enfermedad mental es un problema de salud, discriminando y limitando las oportunidades de las personas que lo padecen. El contacto social con personas que sufren un trastorno mental es una estrategia utilizada para producir cambios en los estereotipos en la población. El objetivo del estudio fue examinar las diferencias en el nivel de estigma en muestras con contacto social y población general. Metodología: El estudio incluye dos experiencias. La primera (n = 42) incluye jugadores de una liga de fútbol abierta en la que juega un equipo de jugadores con diagnóstico de esquizofrenia. En la segunda se compara una muestra sin contacto conocido (n = 62) y una muestra con contacto (n = 100). La herramienta utilizada de evaluación fue el AQ-27, en versión espa˜ nola (AQ-27-E). Se analizaron la diferencia de medias entre las dos muestras, de cada una de las 9 subescalas. Resultados: En la primera experiencia, todas las subescalas presentaron menor puntuación en poscontacto que en precontacto, excepto responsabilidad, dos subescalas que mostraron diferencias significativas fueron coacción (t = 6,057, p = 0,000) y piedad (t = 3,661, p = 0,001). En la segunda experiencia, siete subescalas mostraron nivel de significación (p = <0,05). Responsabilidad y segregación no lo mostraron. Conclusiones: Se observa que el contacto social realizado en entornos cotidianos puede producir un impacto positivo en la reducción del estigma, esto puede contribuir a favorecer la igualdad de oportunidades. © 2017 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction What is known? The stigma surrounding people with mental disorders leads to discriminatory attitudes in daily life situations and fewer opportunities. It has been acknowledged that these people may have less probability of receiving the appropriate standards in health care.
What does this paper contribute? Community guidance provides for an environment of normality in performing daily life activities. This study analyses the difference in stigmatising attitudes of the general public through contact within a framework of daily community coexistence for the whole population. It also reflects on the quality of this contact in community environments.
People who suffer from mental illness are more severely stigmatised than those who are in other medical, social, political or economic circumstances.1---3 Members of the population in general are also less likely to interact with people who have mental disorders.4 For this reason the approach of health professionals in general and nurses in particular is extremely important as a determining factor in the quality of care people with mental disorders receive.5 Stigmatising attitudes foster discrimination in daily life situations, restricting opportunities. As a consequence and out of fear of stigmatisation, people with mental disorders may become isolated from society, resulting in a worsening of their clinical status and their prognosis.6---8 Apart from direct discriminatory experiences caused by other people, those with mental disorders may be affected by structural discrimination, such as lower investment into healthcare resources.9,10 Thus people with mental disorders usually also experience unequal treatment in physical health conditions, and this may contribute to premature morbidity and mortality.11,12 Stigmatisation may be conceptualised as a process which involves complex cognitive---behavioural interactions between the individual and the social environiment.13 There are several different components to stigma: stereotypes,
+Model
ARTICLE IN PRESS
Stigma: The relevance of social contact in mental disorder separation, loss of status and discrimination with stigmatisation occurring when it is exercised from a position of power,14 and thus becomes disparagement and a mark of dishonour generally leading to negative behaviour by whomever engages in it. Although the concept of stigma is essential for the understanding of the experience of social exclusion, it falls short of a full explanation, since the actions to promote social inclusion are not identified. Three interrelated problems were identified in stigma: the problem of awareness (ignorance), the problem of attitude (prejudice) and the problem of behaviour (discrimination).15---17 Different theoretical approaches have been developed to provide answers to these problems related to stigma in mental health, including the social cognitive models18 where relevance is given to stereotypes (negative beliefs about a group), prejudice (negative emotional reactions such as fear and/or anger, in keeping with stereotyped beliefs), and discrimination (exclusion of social and economic opportunities as a consequence of prejudice behaviour patterns). Studies have been conducted on strategies required to change stereotypes and have identified three approaches for changing stereotyped attitudes: education aimed at replacing stigmatising attitudes with exact notions regarding the disorder; contact which seeks change through direct interrelationship with people with a disorder; and protest, which seeks to remove stigmatising attitudes towards people with mental disorders.18 Until very recently these studies assessed change in knowledge or attitude or both, but did not evaluate the impact in behaviour.19 Corrigan et al.’s meta-analysis on interventions to deal with public stigma concluded that direct contact was better than filmed contact, and for adults, contact was more effective than education.20 As we have already stated, one of the ways of changing the general public’s attitude to mental illness is to promote their interaction with people with mental disorders, although it is also accepted that more research into this area is required to determine the effects of this contact.21 At present, several systematic reviews support the idea that social contact is the most effective intervention for adults.22 The aim of this study was to examine the differences in stigma between the population at large and the population who had social contact with people with mental disorders. To do this, parallel samples were analysed in the two different community experiences.
Method There were two different types of experience. The first had a pre- and post-contact design and the second a transversal cut with two different samples. The stigma evaluation tool used was the AQ-27, in its Spanish version (AQ-27-E). The Attribution Questionnaire, was initially created by Weiner et al. (1988), with different revisions being made. Corrigan, Watson, Warpinski and Gracia (2004) increased the number of items to 27, configuring the Attribution Questionnaire 27 (AQ-27),23---25 which was finally used in the two experiences in its version translated into the Spanish language by Mu˜ noz et al.25
3 The first experience consisted in promoting social contact through participation in five-aside football, formed by 11 players with a diagnosis of schizophrenia in a championship open to the whole population. The team appointed a captain, who was in charge of registration and going to the coordination meetings arranged by the championship management. This captain was also responsible for communicating information in both directions, from the tournament management to the team members and vice versa. Initial evaluation (pre-) was made once the tournament had begun: the team members of the other teams were asked to respond to questionnaire AQ-27-E. For sample recruitment purposes a meeting was organised with a representative from each team where they were informed of the assessment study of mental health perception and invited to take part in it and also to extend the invitation to the rest of the team. 63 people responded to this initial assessment. At the end of the tournament, four months later, the players who had responded to the pre-assessment were requested to do so a second time (post). They were previously informed that they had been playing with a team made up of people with mental disorders. 42 people responded to this assessment, and the final study sample was therefore (No. = 42). The second experience evaluated social contact through daily coexistence, conducted with two separate samples. The first was obtained by requesting that the general public fill in questionnaire AQ-27-E. In this first sample we were looking for the opinion of the general public regardless of the level of knowledge or lack of knowledge they had in relation to mental disorders. 64 people responded to the questionnaire (No. = 64). The second sample was obtained from people who attended a community centre. Common spaces in this community centre were shared with people with mental disorders, who carried out activities there. The users of the community centre were requested to fill out questionnaire AQ-27-E. 100 people responded (No. = 100). Participation was voluntary in both experiences, with previous requirement of an informed consent form signature. Exclusion criteria were: forming part of the team of people with MD, not understanding the Catalan language and being under 18. Both experiences were carried out in the municipality of Sta. Coloma de Gramenet, a town of 119,182 inhabitants, located in the province of Barcelona. A mental health monographic hospital has existed in this town since 1930. At present, apart from psychiatric hospitalisation units there are also community healthcare services integrated into the network of public healthcare for mental health. People with mental disorders who formed part of the football team were linked to the public healthcare system, regularly attended the community rehabilitation centre and periodically visited the Adult Mental Health Centre. Ethical approval was given by the Ethics Clinical Research Committee of the Parc de Salut Mar de Barcelona in February 2015. Data collection was made between March and July 2015.
Measurement instruments The AQ-27-E scale is based on the theory of attribution including the blame model as a part of stigma explanation.
+Model
ARTICLE IN PRESS
4 The blame model identifies two modes of operation. When the persona with the disorder is attributed with blame for it or that can exercise some control over it, this perception leads to anger with states of control, punishment or repression. If the person is regarded as a victim of the disorder or the disorder is considered uncontrollable, the principal attitudes would be pity, and the most common behaviour pattern would be of helping.18,25 Corrigan18 also observed behaviour patterns related to the perception of danger, thus incorporating a second model. With this the attribution of dangerous behaviour patterns to a person leads to fear which in turn leads to apprehension or a state of avoidance. In 2004, Corrigan et al.26 finalised the number of items at 27 (AQ-27) and the number of factors at nine: blame, pity, anger, dangerousness, fear, help, coercion, segregation and avoidance. Questionnaire AQ-27-E is a selfadministered measurement tool designed to assess attitudes and behaviours relating to mental health: it includes a hypothetical character (José) who suffers from a severe mental disorder. The questionnaire is based on the two explanatory models of stigma: the theory of attribution and the theory of dangerousness.25,26 It contains 27 items which are structured into the 9 subscales mentioned above, of 3 items each. The 27 items are evaluated in a Likert type format of 9 points, which range from absolutely not (1 point) to a lot (9 points). The person assessing answers the 27 questions by putting a circle around the one which best reflects their opinion on each of the phrases. Filling-up time takes 10---20 min. The result of each one of the 9 subscales is obtained with the sum of the 3 corresponding items; the observable range in score of the subscales oscillates between 3 and 27. Questionnaire AQ-27 has been translated and validated into the Spanish language by Mu˜ noz et al. In the validation study the reliability of AQ-27-E was tested, and demonstrated a Crombach alpha of 0.855 for the whole scale. It also presented enough psychometric properties for the evaluation of stigma in the Spanish speaking population.25 Sociodemocratic variables were also collected through basic questions regarding age, gender and level of education.
Statistical analysis Sociodemographic variables were studied using descriptive statistics. The difference between means were analysed for study analysis, in the two experiences, of each of AQ-27-E subscales, between pre and post contact in sports activity, general population and contact with people with mental disorders in everyday co-existence. For this analysis of means the Student’s t-test was used for dependent samples in the first experience and for independent samples in the second.
Results In the football tournament experience the sample was of 42 people (No. = 42). 100% were men, each with a mean age of 33 (SD = 10.38) and ranged between 19 and 64.
V.M. Frías et al. Educational level was mainly secondary school (63.4%) followed by university level (22%). Once the comparison of means of the AQ-27-E subscales had been made, the two which presented greater variation were coercion, with a drop of 4.33 points, and pity with a drop of 2.71 points between the first (pre-) and second (post-) completion. These two subscales were the only ones with significant differences: coercion (t = 6.057, p = 0.000) and pity (t = 3.661, p = 0.001) (Table 1). In general the means of all the subscales presented a lower score in the post session than in the pre-, with the exception of blame, which presented an increase of 0.85 points and avoidance, which presented an increase of 1.28 points, although in this subscale the reading of the result should be inverted. Help was practically the same, with a slight increase of 0.05 points (Table 1). In the second experience, the general population sample presented with a distribution by gender in which women were the majority (62.1%). Mean age was 44 (SD = 15.13) with a range of between 19 and 77. Education level was mostly primary (36.5%) followed by secondary (34.9%). In the sample where they were contact with people with mental disorders, women represented 69%, with a mean age of 55 (SD = 18.59) with a range of between 19 and 87. Level of education was mainly primary (58.7%) followed by secondary (25%). In the comparison of means of the AQ-27-E subscales, six of them (blame, anger, dangerousness, fear, coercion and segregation) presented lower scores in the group with contact compared with the general public group (Table 2). In pity, help and avoidance there was, however, a higher score. The four subscales with the greatest difference were: help with a difference of 3.68 points, dangerousness with a difference of 3.00 points, avoidance with a difference of 2.85 points (should be read inversely) and fear with a difference of 2.68 points. Of the nine subscales, seven showed significance levels (p < 0.05). On the contrary, blame and segregation did not show this.
Discussion Social contact may lead to an improvement in the general public’s attitudes towards people suffering from a mental disorder. In the second experience the comparison between the two samples suggested that contact through everyday relationships allows people to learn how to act, feel and think positively about the mental disorder. This positive attitude encouraged greater control over different situations which could arise when a relationship with a person with a mental disorder was established, with good results.27 The results of this research were in line with other previous studies, which showed that attitudes may change through social contact,27---29 with greater impact being observed when this contact occurred through a daily relationship and for a prolonged amount of time. It should be noted that in the programmed sports activity, although positive changes occurred in all dimensions, they were significant in pity and segregation; i.e. people who had been involved in the football activity when made aware of the participation of a team made up of people with mental disorders appeared to improve in their
+Model
ARTICLE IN PRESS
Stigma: The relevance of social contact in mental disorder Table 1
5
Analysis of means regarding football tournament (No. = 42), Student’s t-test.
Dimensions
Pre-contact T1 Mean (SD)
Post-contact T2 Mean (SD)
CI = 95% Low-high
t
p
Blame Pity Anger Dangerousness Fear Help Coercion Segregation Avoidance
10.17 (3.305) 17.43 (3.826) 7.52 (3.730) 9.31 (4.662) 7.33 (4.476) 19.52 (5.167) 21.24 (3.587) 10.9 (4.487) 16.48 (6.840)
11.02 (3.732) 14.71 (3.744) 6.93 (4.447) 8.29 (5.004) 6.67 (4.365) 1.9.57(6.333) 16.9 (3.420) 9.95 (5.118) 17.46 (6.096)
−2.221; 1.217; −0.927; −0.424; −0.969; −2.110; 2.889; −1.038; −3.182;
−1.269 3.661 0.790 1.428 0.823 −0.047 6.057 0.967 −1.369
0.211 0.001* 0.434 0.161 0.415 0.963 0.000* 0.339 0.178
*
0.507 4.212 2.117 2.472 2.302 2.015 5.778 2.942 0.611
Significance, p ≤ 0.05.
Table 2 Analysis of means on everyday coexistence, general population (GP) (No. = 64) and population with contact (PCC) (No. = 100), Student’s t-test. Dimensions
GP Mean (SD)
Blame
10.25(3.528)
9.68(4.261)
Pity
14.75(5.195)
17.26(4.788)
Anger Dangerousness Fear Help
7.48(4.442) 9.47(5.481) 8.67(5.774) 18.38(6.093)
5.75(4.101) 6.47(4.745) 5.99(4.676) 22.06(5.363)
Coercion Segregation
20.31(4.268) 9.77(5.629)
18.41(6.344) 8.07(6.296)
Avoidance
15.53(7,509)
18.39(6.809)
*
Yes contact Mean (SD)
CI = 95% Low-high −0.692; 1.832 −4.075; −0.945 0.407; 3.062 1.419; 4.581 1.060; 4.304 −5.474; −1.896 0.123; 3.682 −0.189; 3.594 −5.100; −0.618
t
p 0.892
0.374
−3.168
0.002*
2.580 3.746 3.265 −4.068
0.011* 0.000* 0.001* 0.000*
2.112 1.777
0.036* 0.077
−2.519
0.013*
Significance, p ≤ 0.05.
attitude in these two dimensions. Moreover, with regards to the second experience, positive differences were also observed in all dimensions, with these differences being significant to greater degree in the dimensions of pity, anger, dangerousness, fear, help, coercion and avoidance, which suggests a more positive attitude in people if they spontaneously take part in daily activities without these having to be organised.30 In contrast, from the attribution and dangerousness models, it may be deduced that in the second experience there were differences in the approach to the mental disorder with the person considering themselves more as a victim than as to blame for their illness, and also with a lower perception of dangerousness.25,26 As may be observed, the number of dimensions in which significant differences are appreciated was greater in the second experience than in the first. This could be explained by the fact than in the first, although participants were aware that they had coexisted with people with mental disorders, they did not identify with them. In contrast, in the second, the people who participated did know these people which underlines the importance of not just having contact
but also a personal and social relationship between the different people. This leads us to the need to reflect on the impact of the quality of the contact in modifying stigmatising attitudes. In turn, it emphasizes the importance of having regular and prolonged contact time which was the case in the second study compared to the sporadic contact in the first study for improving attitudes to people with mental disorders. When comparing the results between the two experiences, it was observed that in two dimensions behaviour was different. On the one hand, pity decreased in sports activity but scored higher in the contact sample of the second study. Help, which did not change in the football study, scored higher in the continuous contact sample of the second experience. As previously mentioned, an explanation could be in the attribution model, placing greater blame on the illness of the person with a mental disorder in the first study and appearing as a victim in the second.25,26 Observation showed that the everyday relationship and greater duration of the second experience, established closer, more personal relationships which led to greater
+Model
ARTICLE IN PRESS
6 involvement in the personal circumstances of the other person. For their part, the dimensions representing the perception of danger (dangerousness, fear and avoidance) scored lower in the samples with contact in both studies. This major reduction in the perception of danger could also be explained by the more everyday relationship and longer duration. Greater knowledge of the person would help to change preconceived ideas, removing fear and the sensation of dangerousness. Lastly, we would highlight that with regards to the experience of the football championship, participants were informed that they had been competing with a team of people with mental disorders. As previously mentioned, we believe the information given to them was sufficient but we must highlight as a limitation the refusal of the people with mental disorders to be identified as such. Moreover, this aspect is related to the concept of selfstigma which people with a mental disorder may suffer.31 In addition, the gender variable in the football study should be taken into account since in this case all participants were men, and this could have affected the attribution of blame for their disorder. From the studies conducted and the results obtained we observe that social contact lowers the stigma against people with mental disorders. Regular, prolonged contact with people who have a mental disorder appears to lead to less stigma than occasional, limited contact with them over time. We also observed that social contact made in environments used by the general population (sporty, cultural), produced a positive impact in the reduction of stigma, and we also think that by placing people with mental disorders on the same level as the general public promotes equal opportunities. We therefore reiterate the importance of establishing collaborative strategies between the community and the nursing professionals, in their commitment to establish plans of action and collaborative work to help reduce stigma. Further investigation needs to be made on awareness of the reduction of the stigma surrounding mental disorder, through conducting new studies to research into strategies which are based on social contact in community environments open to the general public, introducing the variable of quality contact as a factor for reflection.
Conflict of interests The authors have no conflict of interests to declare.
Acknowledgements The authors would like to thank R. Pascual and his team for their contribution in the football championship study, to G. Quero, coordinator of the Community Centre in barri llatí and to P. Rodríguez and the whole coordination team of the community centres of the Town Council of Sta. Coloma de Gramenet. We would also like to thank D. Ávalos and P. Gómez.
V.M. Frías et al.
References 1. Marwaha S, Johnson S. Views and experiences of employment among people with psychosis: a qualitative descriptive study. Int J Soc Psychiatry. 2005;51:302---16. 2. Baumann A. Stigmatization, social distance and exclusion because of mental illness: the individual with mental illness as a ‘stranger’. Int Rev Psychiatry. 2007;19:131---5. 3. El-Badri S, Mellsop G. Stigma and quality of life as experienced by people with mental illness. Australas Psychiatry. 2007;15:195---200. 4. Halter M. Perceived characteristics of psychiatric nurses: stigma by association. Arch Psychiatr Nurs. 2008;22:20---6. 5. Kassam A, Glozier N, Leese M, Henderson C, Thornicroft G. Development and responsiveness of a scale to measure clinicians’ attitudes to people with mental illness. Acta Psychiatr Scand. 2010;122:153---61. 6. Vauth R, Kleim B, Wirtz M, Corrigan P. Self-efficacy and empowerment as outcomes of self-stigmatizing and coping in schizophrenia. Psychiatry Res. 2007;150:71---80. 7. Yap MB, Wright A, Jorm AF. The influence of stigma on young people’s help-seeking intentions and beliefs about the helpfulness of various sources of help. Soc Psychiatry Psychiatr Epidemiol. 2010. 8. Mojtabai R. Mental illness stigma and willingness to seek mental health care in the European Union. Soc Psychiatry Psychiatr Epidemiol. 2010;45:705---12. 9. Corrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004;30:481---91. 10. Link BG, Phelan JC. On stigma and its public health implications. Stigma and global health: developing a research agenda;. MD, USA: Bethesda; 2001. Sept 5---7. 11. Thornicroft G. Premature death among people with mental illness. BMJ. 2013;346:f2969. 12. Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry. 2011;199:441---2. 13. Norman RM, Sorrentino RM, Gawronski B, Szeto AC, Ye Y, Windell D. Attitudes and physical distance to an individual with schizophrenia: the moderating effect of self-transcendent values. Soc Psychiatry Psychiatr Epidemiol. 2010;45:751---8. 14. Link BG, Phelan JC. Conceptualizing stigma. Annual Rev Sociol. 2001;27:363---85. 15. Thornicroft G, Brohan E, Kassam A, Lewis-Holmes E. Reducing stigma and discrimination: candidate interventions. Int J Ment Health Syst. 2008;2:3. 16. Thornicroft G, Rose D, Kassam A, Sartorius N. Stigma: ignorance, prejudice or discrimination? Br J Psychiatry. 2007;190:192---3. 17. Thornicroft G. Shunned: discrimination against people with mental illness. Oxford: Oxford University Press; 2006. 18. Corrigan PW. Mental health stigma as social attribution: implications for research methods and attitude change. Clin Psychol Sci Pract. 2000;7:48---67. 19. Thornicroft G, Mehta N, Clement S, Evans-Lacko S, Doherty M, Rose D, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet. 2016;358:2110---2. 20. Yang L, Cho SH, Kleinman A. Stigma of mental illness. In: Patel V, editor. Mental and neurological public health: a global perspective. Elsevier; 2010. 21. Corrigan PW, River LP, Lundin RK, Penn DL, Uphoff-Wasowski K, Campion J, et al. Three strategies for changing attributions about severe mental illness. Schizophr Bull. 2001;27:187---95. 22. Mehta N, Clement S, Marcus E, Stona A-C, Bezborodovs N, Evans Lacko S, et al. Evidence for effective interventions to reduce mental health-related stigma and discrimination in the
+Model
ARTICLE IN PRESS
Stigma: The relevance of social contact in mental disorder
23.
24.
25.
26.
medium and long term: systematic review. Br J Psychiatry. 2015;207:377---84. Weiner B, Perry RP, Magnusson J. An attribution al analysis of reactions to stigmas. J Pers Soc Psychol. 1988;55:738---48, 1988. Reisenzein R. A structural equation analysis of Weiner’s attribution-affect model of helping behavior. J Pers Soc Psychol. 1986;50:1123---33. Mu˜ noz M, Guillén AI, Pérez-Santos E, Corrigan PW. A structural equation modeling study of the Spanish Mental Illness Stigma Attribution Questionnaire (AQ-27-E). Am J Ortho Psychiatry. 2015;85:243---9. Corrigan PW, Rowan D, Green A, Lundin R, River P, UphoffWasowski K, et al. Challenging two mental illness stigmas: personal responsibility and dangerousness. Schizophrenia Bull. 2002;28:293---309.
7 27. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rüsch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv. 2012;63:963---73. 28. Schachter HM, Girardi A, Ly M, Lacroix D, Lumb AB, van Berkom JR, et al. Effects of school-based interventions on mental health stigmatization: a systematic review. Child Adolesc Psychiatry Ment Health. 2008;2:18. 29. Evans-Lacko S, Malcolm E, West K, Rose D, London J, Rusch N, et al. Influence of Time to Change’s social marketing interventions on stigma in England 2009-2011. Br J Psychiatry Suppl. 2013;55:s77---88. 30. National Institute of Health and Clinical Excellence. Behaviour change at population, community and individual levels. Available in: http://www.nice.org.uk/PH006; 2007. 31. Corrigan P, Watson A. The paradox of self-stigma and mental illness. Clin Psychol Sci Pract. 2006;9:35---53.
ARTICLE IN PRESS
Enferm Clin. 2017;xxx(xx):xxx---xxx
www.elsevier.es/enfermeriaclinica
ORIGINAL ARTICLE
Stigma: The relevance of social contact in mental disorder夽 Víctor M. Fríasa,b,∗ , Joan R. Fortunya , Sergio Guzmána , Pilar Santamaríaa , Montserrat Martínezc , Víctor Pérezd,e,f a
Institut de Neuropsiquiatria i Addicions, Centre Assitencial Dr. Emili Mira, Parc de Salut Mar, Santa Coloma de Gramenet, Barcelona, Spain b Departament de Psiquiatria, Universitat Autònoma de Barcelona, Barcelona, Spain c Gestió del Coneixement i Avaluació, Hospital Universitari Vall d’Hebron, Barcelona, Spain d Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Spain e Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain f CIBERSAM, Departament de Psiquiatria, Universitat Autònoma de Barcelona, Barcelona, Spain Received 19 November 2016; accepted 26 May 2017
KEYWORDS Stigma; Social contact; Mental illness; Mental disorder; Schizophrenia; Community programmes
Abstract Introduction: The stigma associated with mental illness is a health problem, discriminating and limiting the opportunities for sufferers. Social contact with people suffering a mental disorder is a strategy used to produce changes in population stereotypes. The aim of the study was to examine differences in the level of stigma in samples with social contact and the general population. Method: The study included two experiments. The first (n = 42) included players in an open football league who played in a team with players with schizophrenia. In the second included, a sample without known contact (n = 62) and a sample with contact (n = 100) were compared. The evaluation tool used was AQ-27, Spanish version (AQ-27-E). The mean difference between the two samples of each of the 9 subscales was analysed. Results: In the first experiment, all the subscales had lower scores in post-contact than in precontact, except for responsibility. The two subscales that showed significant differences were duress (t = 6.057, p = 0.000) and Pity (t = 3.661, p = 0.001). In the second experiment, seven subscales showed a significance level (p < 0.05). Segregation and responsibility and did not.
DOI of original article: http://dx.doi.org/10.1016/j.enfcli.2017.05.007 Please cite this article as: Frías VM, Fortuny JR, Guzmán S, Santamaría P, Martínez M, Pérez V. Estigma: la relevancia del contacto social en el trastorno mental. Enferm Clin. 2017. http://dx.doi.org/10.1016/j.enfcli.2017.05.007 ∗ Corresponding author. E-mail address: [email protected] (V.M. Frías). 夽
2445-1479/© 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.
ENFCLE-688; No. of Pages 7
+Model
ARTICLE IN PRESS
2
V.M. Frías et al. Conclusions: It is observed that the social contact made in daily situations can have a positive impact on the reduction of stigma. This can help to promote equality of opportunity. © 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.
PALABRAS CLAVE Estigma; Contacto social; Enfermedad mental; Trastorno mental; Esquizofrenia; Programas comunitarios
Estigma: la relevancia del contacto social en el trastorno mental Resumen Introducción: El estigma asociado a la enfermedad mental es un problema de salud, discriminando y limitando las oportunidades de las personas que lo padecen. El contacto social con personas que sufren un trastorno mental es una estrategia utilizada para producir cambios en los estereotipos en la población. El objetivo del estudio fue examinar las diferencias en el nivel de estigma en muestras con contacto social y población general. Metodología: El estudio incluye dos experiencias. La primera (n = 42) incluye jugadores de una liga de fútbol abierta en la que juega un equipo de jugadores con diagnóstico de esquizofrenia. En la segunda se compara una muestra sin contacto conocido (n = 62) y una muestra con contacto (n = 100). La herramienta utilizada de evaluación fue el AQ-27, en versión espa˜ nola (AQ-27-E). Se analizaron la diferencia de medias entre las dos muestras, de cada una de las 9 subescalas. Resultados: En la primera experiencia, todas las subescalas presentaron menor puntuación en poscontacto que en precontacto, excepto responsabilidad, dos subescalas que mostraron diferencias significativas fueron coacción (t = 6,057, p = 0,000) y piedad (t = 3,661, p = 0,001). En la segunda experiencia, siete subescalas mostraron nivel de significación (p = <0,05). Responsabilidad y segregación no lo mostraron. Conclusiones: Se observa que el contacto social realizado en entornos cotidianos puede producir un impacto positivo en la reducción del estigma, esto puede contribuir a favorecer la igualdad de oportunidades. © 2017 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction What is known? The stigma surrounding people with mental disorders leads to discriminatory attitudes in daily life situations and fewer opportunities. It has been acknowledged that these people may have less probability of receiving the appropriate standards in health care.
What does this paper contribute? Community guidance provides for an environment of normality in performing daily life activities. This study analyses the difference in stigmatising attitudes of the general public through contact within a framework of daily community coexistence for the whole population. It also reflects on the quality of this contact in community environments.
People who suffer from mental illness are more severely stigmatised than those who are in other medical, social, political or economic circumstances.1---3 Members of the population in general are also less likely to interact with people who have mental disorders.4 For this reason the approach of health professionals in general and nurses in particular is extremely important as a determining factor in the quality of care people with mental disorders receive.5 Stigmatising attitudes foster discrimination in daily life situations, restricting opportunities. As a consequence and out of fear of stigmatisation, people with mental disorders may become isolated from society, resulting in a worsening of their clinical status and their prognosis.6---8 Apart from direct discriminatory experiences caused by other people, those with mental disorders may be affected by structural discrimination, such as lower investment into healthcare resources.9,10 Thus people with mental disorders usually also experience unequal treatment in physical health conditions, and this may contribute to premature morbidity and mortality.11,12 Stigmatisation may be conceptualised as a process which involves complex cognitive---behavioural interactions between the individual and the social environiment.13 There are several different components to stigma: stereotypes,
+Model
ARTICLE IN PRESS
Stigma: The relevance of social contact in mental disorder separation, loss of status and discrimination with stigmatisation occurring when it is exercised from a position of power,14 and thus becomes disparagement and a mark of dishonour generally leading to negative behaviour by whomever engages in it. Although the concept of stigma is essential for the understanding of the experience of social exclusion, it falls short of a full explanation, since the actions to promote social inclusion are not identified. Three interrelated problems were identified in stigma: the problem of awareness (ignorance), the problem of attitude (prejudice) and the problem of behaviour (discrimination).15---17 Different theoretical approaches have been developed to provide answers to these problems related to stigma in mental health, including the social cognitive models18 where relevance is given to stereotypes (negative beliefs about a group), prejudice (negative emotional reactions such as fear and/or anger, in keeping with stereotyped beliefs), and discrimination (exclusion of social and economic opportunities as a consequence of prejudice behaviour patterns). Studies have been conducted on strategies required to change stereotypes and have identified three approaches for changing stereotyped attitudes: education aimed at replacing stigmatising attitudes with exact notions regarding the disorder; contact which seeks change through direct interrelationship with people with a disorder; and protest, which seeks to remove stigmatising attitudes towards people with mental disorders.18 Until very recently these studies assessed change in knowledge or attitude or both, but did not evaluate the impact in behaviour.19 Corrigan et al.’s meta-analysis on interventions to deal with public stigma concluded that direct contact was better than filmed contact, and for adults, contact was more effective than education.20 As we have already stated, one of the ways of changing the general public’s attitude to mental illness is to promote their interaction with people with mental disorders, although it is also accepted that more research into this area is required to determine the effects of this contact.21 At present, several systematic reviews support the idea that social contact is the most effective intervention for adults.22 The aim of this study was to examine the differences in stigma between the population at large and the population who had social contact with people with mental disorders. To do this, parallel samples were analysed in the two different community experiences.
Method There were two different types of experience. The first had a pre- and post-contact design and the second a transversal cut with two different samples. The stigma evaluation tool used was the AQ-27, in its Spanish version (AQ-27-E). The Attribution Questionnaire, was initially created by Weiner et al. (1988), with different revisions being made. Corrigan, Watson, Warpinski and Gracia (2004) increased the number of items to 27, configuring the Attribution Questionnaire 27 (AQ-27),23---25 which was finally used in the two experiences in its version translated into the Spanish language by Mu˜ noz et al.25
3 The first experience consisted in promoting social contact through participation in five-aside football, formed by 11 players with a diagnosis of schizophrenia in a championship open to the whole population. The team appointed a captain, who was in charge of registration and going to the coordination meetings arranged by the championship management. This captain was also responsible for communicating information in both directions, from the tournament management to the team members and vice versa. Initial evaluation (pre-) was made once the tournament had begun: the team members of the other teams were asked to respond to questionnaire AQ-27-E. For sample recruitment purposes a meeting was organised with a representative from each team where they were informed of the assessment study of mental health perception and invited to take part in it and also to extend the invitation to the rest of the team. 63 people responded to this initial assessment. At the end of the tournament, four months later, the players who had responded to the pre-assessment were requested to do so a second time (post). They were previously informed that they had been playing with a team made up of people with mental disorders. 42 people responded to this assessment, and the final study sample was therefore (No. = 42). The second experience evaluated social contact through daily coexistence, conducted with two separate samples. The first was obtained by requesting that the general public fill in questionnaire AQ-27-E. In this first sample we were looking for the opinion of the general public regardless of the level of knowledge or lack of knowledge they had in relation to mental disorders. 64 people responded to the questionnaire (No. = 64). The second sample was obtained from people who attended a community centre. Common spaces in this community centre were shared with people with mental disorders, who carried out activities there. The users of the community centre were requested to fill out questionnaire AQ-27-E. 100 people responded (No. = 100). Participation was voluntary in both experiences, with previous requirement of an informed consent form signature. Exclusion criteria were: forming part of the team of people with MD, not understanding the Catalan language and being under 18. Both experiences were carried out in the municipality of Sta. Coloma de Gramenet, a town of 119,182 inhabitants, located in the province of Barcelona. A mental health monographic hospital has existed in this town since 1930. At present, apart from psychiatric hospitalisation units there are also community healthcare services integrated into the network of public healthcare for mental health. People with mental disorders who formed part of the football team were linked to the public healthcare system, regularly attended the community rehabilitation centre and periodically visited the Adult Mental Health Centre. Ethical approval was given by the Ethics Clinical Research Committee of the Parc de Salut Mar de Barcelona in February 2015. Data collection was made between March and July 2015.
Measurement instruments The AQ-27-E scale is based on the theory of attribution including the blame model as a part of stigma explanation.
+Model
ARTICLE IN PRESS
4 The blame model identifies two modes of operation. When the persona with the disorder is attributed with blame for it or that can exercise some control over it, this perception leads to anger with states of control, punishment or repression. If the person is regarded as a victim of the disorder or the disorder is considered uncontrollable, the principal attitudes would be pity, and the most common behaviour pattern would be of helping.18,25 Corrigan18 also observed behaviour patterns related to the perception of danger, thus incorporating a second model. With this the attribution of dangerous behaviour patterns to a person leads to fear which in turn leads to apprehension or a state of avoidance. In 2004, Corrigan et al.26 finalised the number of items at 27 (AQ-27) and the number of factors at nine: blame, pity, anger, dangerousness, fear, help, coercion, segregation and avoidance. Questionnaire AQ-27-E is a selfadministered measurement tool designed to assess attitudes and behaviours relating to mental health: it includes a hypothetical character (José) who suffers from a severe mental disorder. The questionnaire is based on the two explanatory models of stigma: the theory of attribution and the theory of dangerousness.25,26 It contains 27 items which are structured into the 9 subscales mentioned above, of 3 items each. The 27 items are evaluated in a Likert type format of 9 points, which range from absolutely not (1 point) to a lot (9 points). The person assessing answers the 27 questions by putting a circle around the one which best reflects their opinion on each of the phrases. Filling-up time takes 10---20 min. The result of each one of the 9 subscales is obtained with the sum of the 3 corresponding items; the observable range in score of the subscales oscillates between 3 and 27. Questionnaire AQ-27 has been translated and validated into the Spanish language by Mu˜ noz et al. In the validation study the reliability of AQ-27-E was tested, and demonstrated a Crombach alpha of 0.855 for the whole scale. It also presented enough psychometric properties for the evaluation of stigma in the Spanish speaking population.25 Sociodemocratic variables were also collected through basic questions regarding age, gender and level of education.
Statistical analysis Sociodemographic variables were studied using descriptive statistics. The difference between means were analysed for study analysis, in the two experiences, of each of AQ-27-E subscales, between pre and post contact in sports activity, general population and contact with people with mental disorders in everyday co-existence. For this analysis of means the Student’s t-test was used for dependent samples in the first experience and for independent samples in the second.
Results In the football tournament experience the sample was of 42 people (No. = 42). 100% were men, each with a mean age of 33 (SD = 10.38) and ranged between 19 and 64.
V.M. Frías et al. Educational level was mainly secondary school (63.4%) followed by university level (22%). Once the comparison of means of the AQ-27-E subscales had been made, the two which presented greater variation were coercion, with a drop of 4.33 points, and pity with a drop of 2.71 points between the first (pre-) and second (post-) completion. These two subscales were the only ones with significant differences: coercion (t = 6.057, p = 0.000) and pity (t = 3.661, p = 0.001) (Table 1). In general the means of all the subscales presented a lower score in the post session than in the pre-, with the exception of blame, which presented an increase of 0.85 points and avoidance, which presented an increase of 1.28 points, although in this subscale the reading of the result should be inverted. Help was practically the same, with a slight increase of 0.05 points (Table 1). In the second experience, the general population sample presented with a distribution by gender in which women were the majority (62.1%). Mean age was 44 (SD = 15.13) with a range of between 19 and 77. Education level was mostly primary (36.5%) followed by secondary (34.9%). In the sample where they were contact with people with mental disorders, women represented 69%, with a mean age of 55 (SD = 18.59) with a range of between 19 and 87. Level of education was mainly primary (58.7%) followed by secondary (25%). In the comparison of means of the AQ-27-E subscales, six of them (blame, anger, dangerousness, fear, coercion and segregation) presented lower scores in the group with contact compared with the general public group (Table 2). In pity, help and avoidance there was, however, a higher score. The four subscales with the greatest difference were: help with a difference of 3.68 points, dangerousness with a difference of 3.00 points, avoidance with a difference of 2.85 points (should be read inversely) and fear with a difference of 2.68 points. Of the nine subscales, seven showed significance levels (p < 0.05). On the contrary, blame and segregation did not show this.
Discussion Social contact may lead to an improvement in the general public’s attitudes towards people suffering from a mental disorder. In the second experience the comparison between the two samples suggested that contact through everyday relationships allows people to learn how to act, feel and think positively about the mental disorder. This positive attitude encouraged greater control over different situations which could arise when a relationship with a person with a mental disorder was established, with good results.27 The results of this research were in line with other previous studies, which showed that attitudes may change through social contact,27---29 with greater impact being observed when this contact occurred through a daily relationship and for a prolonged amount of time. It should be noted that in the programmed sports activity, although positive changes occurred in all dimensions, they were significant in pity and segregation; i.e. people who had been involved in the football activity when made aware of the participation of a team made up of people with mental disorders appeared to improve in their
+Model
ARTICLE IN PRESS
Stigma: The relevance of social contact in mental disorder Table 1
5
Analysis of means regarding football tournament (No. = 42), Student’s t-test.
Dimensions
Pre-contact T1 Mean (SD)
Post-contact T2 Mean (SD)
CI = 95% Low-high
t
p
Blame Pity Anger Dangerousness Fear Help Coercion Segregation Avoidance
10.17 (3.305) 17.43 (3.826) 7.52 (3.730) 9.31 (4.662) 7.33 (4.476) 19.52 (5.167) 21.24 (3.587) 10.9 (4.487) 16.48 (6.840)
11.02 (3.732) 14.71 (3.744) 6.93 (4.447) 8.29 (5.004) 6.67 (4.365) 1.9.57(6.333) 16.9 (3.420) 9.95 (5.118) 17.46 (6.096)
−2.221; 1.217; −0.927; −0.424; −0.969; −2.110; 2.889; −1.038; −3.182;
−1.269 3.661 0.790 1.428 0.823 −0.047 6.057 0.967 −1.369
0.211 0.001* 0.434 0.161 0.415 0.963 0.000* 0.339 0.178
*
0.507 4.212 2.117 2.472 2.302 2.015 5.778 2.942 0.611
Significance, p ≤ 0.05.
Table 2 Analysis of means on everyday coexistence, general population (GP) (No. = 64) and population with contact (PCC) (No. = 100), Student’s t-test. Dimensions
GP Mean (SD)
Blame
10.25(3.528)
9.68(4.261)
Pity
14.75(5.195)
17.26(4.788)
Anger Dangerousness Fear Help
7.48(4.442) 9.47(5.481) 8.67(5.774) 18.38(6.093)
5.75(4.101) 6.47(4.745) 5.99(4.676) 22.06(5.363)
Coercion Segregation
20.31(4.268) 9.77(5.629)
18.41(6.344) 8.07(6.296)
Avoidance
15.53(7,509)
18.39(6.809)
*
Yes contact Mean (SD)
CI = 95% Low-high −0.692; 1.832 −4.075; −0.945 0.407; 3.062 1.419; 4.581 1.060; 4.304 −5.474; −1.896 0.123; 3.682 −0.189; 3.594 −5.100; −0.618
t
p 0.892
0.374
−3.168
0.002*
2.580 3.746 3.265 −4.068
0.011* 0.000* 0.001* 0.000*
2.112 1.777
0.036* 0.077
−2.519
0.013*
Significance, p ≤ 0.05.
attitude in these two dimensions. Moreover, with regards to the second experience, positive differences were also observed in all dimensions, with these differences being significant to greater degree in the dimensions of pity, anger, dangerousness, fear, help, coercion and avoidance, which suggests a more positive attitude in people if they spontaneously take part in daily activities without these having to be organised.30 In contrast, from the attribution and dangerousness models, it may be deduced that in the second experience there were differences in the approach to the mental disorder with the person considering themselves more as a victim than as to blame for their illness, and also with a lower perception of dangerousness.25,26 As may be observed, the number of dimensions in which significant differences are appreciated was greater in the second experience than in the first. This could be explained by the fact than in the first, although participants were aware that they had coexisted with people with mental disorders, they did not identify with them. In contrast, in the second, the people who participated did know these people which underlines the importance of not just having contact
but also a personal and social relationship between the different people. This leads us to the need to reflect on the impact of the quality of the contact in modifying stigmatising attitudes. In turn, it emphasizes the importance of having regular and prolonged contact time which was the case in the second study compared to the sporadic contact in the first study for improving attitudes to people with mental disorders. When comparing the results between the two experiences, it was observed that in two dimensions behaviour was different. On the one hand, pity decreased in sports activity but scored higher in the contact sample of the second study. Help, which did not change in the football study, scored higher in the continuous contact sample of the second experience. As previously mentioned, an explanation could be in the attribution model, placing greater blame on the illness of the person with a mental disorder in the first study and appearing as a victim in the second.25,26 Observation showed that the everyday relationship and greater duration of the second experience, established closer, more personal relationships which led to greater
+Model
ARTICLE IN PRESS
6 involvement in the personal circumstances of the other person. For their part, the dimensions representing the perception of danger (dangerousness, fear and avoidance) scored lower in the samples with contact in both studies. This major reduction in the perception of danger could also be explained by the more everyday relationship and longer duration. Greater knowledge of the person would help to change preconceived ideas, removing fear and the sensation of dangerousness. Lastly, we would highlight that with regards to the experience of the football championship, participants were informed that they had been competing with a team of people with mental disorders. As previously mentioned, we believe the information given to them was sufficient but we must highlight as a limitation the refusal of the people with mental disorders to be identified as such. Moreover, this aspect is related to the concept of selfstigma which people with a mental disorder may suffer.31 In addition, the gender variable in the football study should be taken into account since in this case all participants were men, and this could have affected the attribution of blame for their disorder. From the studies conducted and the results obtained we observe that social contact lowers the stigma against people with mental disorders. Regular, prolonged contact with people who have a mental disorder appears to lead to less stigma than occasional, limited contact with them over time. We also observed that social contact made in environments used by the general population (sporty, cultural), produced a positive impact in the reduction of stigma, and we also think that by placing people with mental disorders on the same level as the general public promotes equal opportunities. We therefore reiterate the importance of establishing collaborative strategies between the community and the nursing professionals, in their commitment to establish plans of action and collaborative work to help reduce stigma. Further investigation needs to be made on awareness of the reduction of the stigma surrounding mental disorder, through conducting new studies to research into strategies which are based on social contact in community environments open to the general public, introducing the variable of quality contact as a factor for reflection.
Conflict of interests The authors have no conflict of interests to declare.
Acknowledgements The authors would like to thank R. Pascual and his team for their contribution in the football championship study, to G. Quero, coordinator of the Community Centre in barri llatí and to P. Rodríguez and the whole coordination team of the community centres of the Town Council of Sta. Coloma de Gramenet. We would also like to thank D. Ávalos and P. Gómez.
V.M. Frías et al.
References 1. Marwaha S, Johnson S. Views and experiences of employment among people with psychosis: a qualitative descriptive study. Int J Soc Psychiatry. 2005;51:302---16. 2. Baumann A. Stigmatization, social distance and exclusion because of mental illness: the individual with mental illness as a ‘stranger’. Int Rev Psychiatry. 2007;19:131---5. 3. El-Badri S, Mellsop G. Stigma and quality of life as experienced by people with mental illness. Australas Psychiatry. 2007;15:195---200. 4. Halter M. Perceived characteristics of psychiatric nurses: stigma by association. Arch Psychiatr Nurs. 2008;22:20---6. 5. Kassam A, Glozier N, Leese M, Henderson C, Thornicroft G. Development and responsiveness of a scale to measure clinicians’ attitudes to people with mental illness. Acta Psychiatr Scand. 2010;122:153---61. 6. Vauth R, Kleim B, Wirtz M, Corrigan P. Self-efficacy and empowerment as outcomes of self-stigmatizing and coping in schizophrenia. Psychiatry Res. 2007;150:71---80. 7. Yap MB, Wright A, Jorm AF. The influence of stigma on young people’s help-seeking intentions and beliefs about the helpfulness of various sources of help. Soc Psychiatry Psychiatr Epidemiol. 2010. 8. Mojtabai R. Mental illness stigma and willingness to seek mental health care in the European Union. Soc Psychiatry Psychiatr Epidemiol. 2010;45:705---12. 9. Corrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004;30:481---91. 10. Link BG, Phelan JC. On stigma and its public health implications. Stigma and global health: developing a research agenda;. MD, USA: Bethesda; 2001. Sept 5---7. 11. Thornicroft G. Premature death among people with mental illness. BMJ. 2013;346:f2969. 12. Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry. 2011;199:441---2. 13. Norman RM, Sorrentino RM, Gawronski B, Szeto AC, Ye Y, Windell D. Attitudes and physical distance to an individual with schizophrenia: the moderating effect of self-transcendent values. Soc Psychiatry Psychiatr Epidemiol. 2010;45:751---8. 14. Link BG, Phelan JC. Conceptualizing stigma. Annual Rev Sociol. 2001;27:363---85. 15. Thornicroft G, Brohan E, Kassam A, Lewis-Holmes E. Reducing stigma and discrimination: candidate interventions. Int J Ment Health Syst. 2008;2:3. 16. Thornicroft G, Rose D, Kassam A, Sartorius N. Stigma: ignorance, prejudice or discrimination? Br J Psychiatry. 2007;190:192---3. 17. Thornicroft G. Shunned: discrimination against people with mental illness. Oxford: Oxford University Press; 2006. 18. Corrigan PW. Mental health stigma as social attribution: implications for research methods and attitude change. Clin Psychol Sci Pract. 2000;7:48---67. 19. Thornicroft G, Mehta N, Clement S, Evans-Lacko S, Doherty M, Rose D, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet. 2016;358:2110---2. 20. Yang L, Cho SH, Kleinman A. Stigma of mental illness. In: Patel V, editor. Mental and neurological public health: a global perspective. Elsevier; 2010. 21. Corrigan PW, River LP, Lundin RK, Penn DL, Uphoff-Wasowski K, Campion J, et al. Three strategies for changing attributions about severe mental illness. Schizophr Bull. 2001;27:187---95. 22. Mehta N, Clement S, Marcus E, Stona A-C, Bezborodovs N, Evans Lacko S, et al. Evidence for effective interventions to reduce mental health-related stigma and discrimination in the
+Model
ARTICLE IN PRESS
Stigma: The relevance of social contact in mental disorder
23.
24.
25.
26.
medium and long term: systematic review. Br J Psychiatry. 2015;207:377---84. Weiner B, Perry RP, Magnusson J. An attribution al analysis of reactions to stigmas. J Pers Soc Psychol. 1988;55:738---48, 1988. Reisenzein R. A structural equation analysis of Weiner’s attribution-affect model of helping behavior. J Pers Soc Psychol. 1986;50:1123---33. Mu˜ noz M, Guillén AI, Pérez-Santos E, Corrigan PW. A structural equation modeling study of the Spanish Mental Illness Stigma Attribution Questionnaire (AQ-27-E). Am J Ortho Psychiatry. 2015;85:243---9. Corrigan PW, Rowan D, Green A, Lundin R, River P, UphoffWasowski K, et al. Challenging two mental illness stigmas: personal responsibility and dangerousness. Schizophrenia Bull. 2002;28:293---309.
7 27. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rüsch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv. 2012;63:963---73. 28. Schachter HM, Girardi A, Ly M, Lacroix D, Lumb AB, van Berkom JR, et al. Effects of school-based interventions on mental health stigmatization: a systematic review. Child Adolesc Psychiatry Ment Health. 2008;2:18. 29. Evans-Lacko S, Malcolm E, West K, Rose D, London J, Rusch N, et al. Influence of Time to Change’s social marketing interventions on stigma in England 2009-2011. Br J Psychiatry Suppl. 2013;55:s77---88. 30. National Institute of Health and Clinical Excellence. Behaviour change at population, community and individual levels. Available in: http://www.nice.org.uk/PH006; 2007. 31. Corrigan P, Watson A. The paradox of self-stigma and mental illness. Clin Psychol Sci Pract. 2006;9:35---53.